In America, there were five patents on scarificators, of which the Smithsonian possesses three patent models. The most significant American patent was that of George Tiemann in 1846. Tiemann"s scarificator had a flattened base and an ebony handle, which contained a coiled spring. The blades were moved by a rack and pinion mechanism, and triggered by a k.n.o.b at the end of the handle. The advantages claimed by the inventor were ease in handling, ease in cleaning, and the diagonal cut of the blades that allowed the blood to flow more freely and the wounds to heal more readily.
Tiemann & Co. was still selling their patent scarificator as late as 1889 for a price of $7.00.[150] The Smithsonian possesses a marketed version in addition to the patent model.
The two other patent scarificators in the Smithsonian collection were both invented by Frederick M. Leypoldt of Philadelphia. The first, patented in 1847, was similar in external appearance to the common scarificator. The novelty consisted of a new arrangement of the c.o.c.king lever and cantilever spring that allowed use of a lighter and cheaper casing. Although the patent model was made of bra.s.s, Leypoldt claimed that with his improvements in the internal mechanism, the case could, with safety, be made of tin.[151]
Leypoldt"s second patent, issued in 1851, was for a scarificator with a greatly simplified inner mechanism allowing for a substantially smaller and lighter case. The c.o.c.king lever was placed horizontally in the casing and engaged the blade rods through a rack and pinion mechanism. According to Leypoldt, this scarificator was more convenient, more portable, cheaper, safer, and more reliable than the common scarificator.[152]
Leypoldt probably marketed his scarificators, there being in the Smithsonian collection other bloodletting instruments with his name, but he did not form a major surgical supply company as did George Tiemann.
[Ill.u.s.tration: FIGURE 16.--Advertis.e.m.e.nt for phlebotomy and cupping instruments. Note the rubber cups. (From George Tiemann & Co., _American Armamentarium Chirurgic.u.m_, New York, 1889. SI photo 76-13542.)]
After 1860, interest in inventing new scarificators declined as wet cupping decreased in popularity. The improved cups and scarificators, while they had achieved a limited success, had still failed to supplant the common octagonal scarificator and the plain gla.s.s cup. As interest in wet cupping declined, medical attention shifted to the therapeutic virtues of dry cupping. Dry cupping offered even greater opportunities for inventors, who sought means to bring the effects of the vacuum to more areas of the body for greater lengths of time.
_Dry Cupping_
Dry cupping, in its simplest form, was said to act as a "revulsive" or "derivant." By the nineteenth century these once hotly debated terms had become nearly interchangeable in discussions of cupping. In cupping for revulsive purposes, one cupped on a distant part to relieve excess of blood in the affected part. In applying cupping as a "derivant," one cupped closer to the affected part. In either case, the source of pain was presumed to be somewhere below the skin, and the pain was relieved by bringing blood away from the affected part to the surface of the body.
Thus, one nineteenth-century cupper concluded, revulsion was only derivation at a distant point.[153]
If dry cupping was applied for ten minutes or longer so that the capillaries burst, the action of the cups was said to be that of a counter-irritant. According to ancient medical theory, the counter-irritant was a means of relieving an affected part by deliberately setting up a secondary inflammation or a running sore in another part.
Counter-irritations were traditionally produced in a number of ways, among them, blisters, cautery, setons, moxa, and dry cupping.[154]
One of the most popular counter-irritation devices commonly a.s.sociated with cupping instruments in catalogs of surgical goods, was Baunscheidt"s _Lebenswecker_, sold by most American surgical supply houses in the second half of the nineteenth century. The _Lebenswecker_, or "Awakener of Life,"
was the mainstay of the mystical medical system known as _Baunscheidtismus_, after the founder of the device, Carl Baunscheidt of Prussia (1809-1860).[155] The system apparently gained much notoriety in Germany, England, and America, for Baunscheidt"s book went through ten German editions and several British and American editions. At least two Americans patented improvements on the _Lebenswecker_.[156] The device was made of ebony, about 250 mm long, and contained a coiled spring attached to a handle. At the other end of the spring was a place about 20 mm in diameter, with about thirty projecting needles. By pushing upon the handle, one sent the needles into the skin. The ability of the instrument to create blisters was enhanced by the application of Baunscheidt"s special oil to the irritation (Figure 17).
[Ill.u.s.tration: FIGURE 17.--Venus and Adonis with marks showing where Baunscheidt"s _Lebenswecker_ should be applied. (From Carl Baunscheidt, _Baunscheidtismus, by the Inventor of the New Curing Method_, Bonn, 1859(?). Photo courtesy of NLM.)]
Dry cupping stimulated much theoretical debate in the nineteenth century as well as a number of physiological experiments.[157] Although physicians generally agreed that dry cupping had curative value if employed properly, they disagreed widely on when to employ the remedy, and on the manner in which the remedy operated. Did application of cups affect only the surface vessels, or could cupping affect the entire nervous system, and through the nerves, the action of the secretory organs? Were the effects of dry cupping of only a temporary nature, or were they permanent? An interesting series of investigations in Europe and America sought to ascertain the value of dry cupping in checking the absorption of poison. An American, Dr. Casper Wistar Pennock, replying to investigations performed by Martin Barry, an Edinburgh physician residing in Paris, carried out an impressive series of physiological experiments in 1827, in which he administered strychnine and a.r.s.enic under the skin of dogs and rabbits and then cupped over the wounds. He concluded that while dry cupping prevented almost certain death from the poisons, once the cups were removed, death would ensue, unless the poisons were surgically removed.[158]
Interest in dry cupping led to attempts to apply the therapeutic effects of the operation to larger areas of the body than could be accommodated by a cup. In France, Victor-Theodore Junod (1809-1881) adapted cupping to entire limbs. Shortly after receiving his degree in medicine in 1833, Junod presented at the Academy of Sciences his apparatus, known thereafter as Junod"s boot. Junod believed that actual extraction of blood was a dangerous remedy and that the benefits of bleeding might as easily be obtained by his "derivative method," which withdrew blood from the general circulation but allowed it to be returned at will. Junod"s boot and Junod"s arm, which sold for as much as $25.00 apiece,[159] were constructed of metal and secured against the limb by a silk, and later a rubber, cap. To the boot was attached a flexible tube, stopc.o.c.k, pump, and if desired, a manometer for measuring the vacuum produced. In chronic illnesses, Junod recommended that the boot be applied for an hour. So much blood was withdrawn from the circulation by use of the apparatus that the patient might easily faint. To explain how his boot worked, Junod invented a theory that he called "hemospasia," meaning the drawing of blood.[160]
This was typical of a number of attempts to introduce sophisticated terminology into discussions of traditional remedies. Junod"s arm and boot were widely available through American surgical supply companies. As late as 1915, Heinrich Stern, previously mentioned as a latter-day proponent of bloodletting, had no doubt that application of the boot to the foot would relieve congested states of the abdominal viscera.[161] (Figure 18.)
Americans patented a number of modifications of the arm and boot, and in addition they patented a number of whole body devices called "depurators."
Junod had introduced such a device along with his boot--a metal casing in which a patient would be placed leaving only his face showing. The air inside would then be exhausted by means of a gigantic syringe. In America such "depurators" may have been regarded more as quackery than as a legitimate extension of cupping, for despite the fact that Americans patented some twenty of these devices, surgical supply houses did not sell them and little was written about them.
In the last decade of the nineteenth century, Dr. August Bier, professor at the University of Bonn, developed another sophisticated theory supporting the use of blood-suction devices, known as the theory of hyperemia, meaning "excess of blood." According to the doctrine, lesions are always accompanied in nature by hyperemia, "the most widespread of auto-curative agents."[162] If we, therefore, wish to imitate nature, we create an artificial hyperemia. Bier recommended several means of increasing the blood supply of an affected part, including hot-air baths, suction devices such as Junod"s boot, and dry cupping. Several American surgical suppliers sold Bier"s Hyperemic Cups in the early twentieth century. These were gla.s.s cups, of a great variety of shapes and sizes including some with curved rims, each fitted with a rubber tube and bulb for exhausting the air. A major function of these cups was to collect wound secretions from boils or furuncles.[163]
[Ill.u.s.tration: FIGURE 18.--Junod"s boot applied to a baby in the cradle.
(From Victor Theodore Junod, _A Theoretical and Practical Treatise on Maemespasia_. London, 1879. Photo courtesy of NLM.)]
_Breast Cupping_
Related to cupping by its technology is the practice of drawing milk from the b.r.e.a.s.t.s by means of breast pumps. Mothers with underdeveloped or inflamed b.r.e.a.s.t.s posed a frequent problem for the nineteenth-century physician, who treated them with either large doses of tartar emetic, a strong purgative, or with cupping.[164] Breast pumps were small gla.s.s cups with fluted edges made to accommodate the nipple. While some surgeons, as the American Samuel Gross, recommended using a bottle with a long neck in which the air had been rarified by means of hot water,[165] most breast pumps were exhausted by mechanical means. For reasons of modesty, the pumps were usually designed so that the woman could draw her b.r.e.a.s.t.s herself. Perhaps the simplest design of a breast pump was a gla.s.s cup having a long spout extending in such a way that the woman could perform suction herself. Such all-gla.s.s cups were ill.u.s.trated in the eighteenth century.[166] A few, reputedly made centuries earlier, are found in the Wellcome Historical Medical Museum. Early in the nineteenth century, breast pumps, just as gla.s.s cups for bleeding, were attached to bra.s.s syringes, and were often included among the variety of cups in cupping sets provided with syringes. Read"s and Weiss"s patent syringe as well as Thomas Mach.e.l.l"s cupping device were adapted for breast pumping. With the invention of vulcanized rubber, the breast pump was frequently attached to a large rubber bulb. A gla.s.s protuberance was often added to pumps exhausted by syringes or rubber bulbs, in order to collect the milk so that it could be fed to the infant. In the 1920s some breast pumps were attached to electric motors.[167] Breast pumps have continued to be employed up to the present day. Of all instruments employing the principle of the cupping device, breast pumps were the most frequently patented.
From 1834 to 1975, more than 60 breast pumps were patented, the majority in the period from 1860 to 1920.[168]
_The Decline of Cupping_
Cupping died out in America in the early twentieth century, but its disappearance was gradual and scarcely noticed. Some of the most complex of cupping devices were invented in a period when most physicians regarded cupping as ineffectual. Patents for cupping devices continued to be issued as late as 1916 when Joel A. Maxam of Idaho Springs, Colorado, patented a motorized pump, which by means of various sizes of cups, could subject a part of the patient"s body to either a prolonged suction or a prolonged compression.[169] One of America"s last advocates of bloodletting, Heinrich Stern, writing in 1915, also advocated the use of an electrical suction pump to evacuate cups. With an electric motor, he declared, one could prolong hyperemia for 15, 30, or more minutes.
Stern also invented a theory to account for the therapeutic effects of his inventions, namely, the theory of phlebostasis. Instead of pumping air out of a device, Stern pumped air into a device, for the same purpose of removing a portion of blood from the general circulation. His "phlebostate," manufactured by Kny-Scheerer of New York, was quite similar to a sphygmomanometer. It consisted of a set of cuffs that fit about the thighs, rubber tubes, a manometer, and a suction bulb or an electric force pump. For stubborn cases, such as migraine headaches, Stern recommended using the cuffs for 30 minutes or more. To facilitate the application of the cuffs, Stern invented a "phlebostasis chair," one of the most complex "cupping" devices ever made. Like an electric chair, the phlebostasis chair was supplied with cuffs for both arms and legs. Air was pumped into the cuffs by means of an electric motor. According to Stern, compression of the upper segment of both arms withheld 300 cc of blood from circulation, while compression of the thighs withheld as much as 600 cc.[170]
In addition to these sophisticated devices, simple cupping, especially dry cupping, continued well into the 1930s. Although cupping was no longer generally recommended by physicians, most surgical companies advertised cups, scarificators, and cupping sets in the 1920s and even the 1930s. The last bastions of cupping in the United States were the immigrant sections of large cities. In the lower East Side of New York, in particular, cupping was still flourishing in the 1920s. By then cupping was no longer performed by the physician, but had been relegated back to the lowly barber, who advertised in his shop window, "Cups for Colds."[171]
Leeching
_Leeches_
The word "leech" derives from the Anglo-Saxon _loece_, "to heal." Thus, the Anglo-Saxon physician was called a "leech" and his textbook of therapeutic methods a "leechdom." The animal itself was already known to the ancients under its Latin name _hirudino_. It appears, however, that the introduction of leeches into Western medicine came somewhat later than that of phlebotomy or cupping, for Hippocrates made no mention of them.
The earliest references to the use of leeches in medicine are found in Nicander of Colophon (2nd century B.C.) and in Themison (1st century B.C.). Thereafter they were mentioned by most Greek, Roman, and Arabic medical writers.[172]
The leech is a fresh-water parasitic invertebrate belonging to the Phylum Annelida. On one end of its worm-like body is a large sucker by which the animal fastens itself to the ground, and at the other end is a smaller sucker, in the middle of which is a chitinous mouth that makes a triangular puncture. As items of _materia medica_, leeches were described in dispensatories, or compilations of medicaments, and sold by apothecaries, both to physicians and directly to patients. The species most commonly used for bleeding was _Hirudo medicinalis_, indigenous to the streams and swamps of Central and Northern Europe, and known in commerce as the Swedish or German leech. It was 50-75 mm long, with a dull olive green back and four yellow longitudinal lines, the central two broken with black. Somewhat less popular was the Hungarian leech, indigenous to Southern Europe. In addition, there was an American species of leech, _Hirudo decora_, which was gathered princ.i.p.ally from the lower Delaware River, but, since it drew much less blood than the Swedish leech, it was regarded as greatly inferior.[173] Most American physicians imported their leeches. In the late nineteenth century, one could buy Swedish leeches for $5.00 per hundred.[174]
Leeches were gathered in the spring of the year either by means of a pole net, or, more primitively, by wading into the water and allowing the leeches to fasten themselves onto the legs. Sometimes horses and cattle were driven into the water to serve as bait for the leeches.[175] (Figure 19.)
[Ill.u.s.tration: FIGURE 19.--Lithograph published in London in 1814 showing three women gathering leeches by a stream. (NMHT 320033.08; SI photo 76-7741.)]
Leeching, like other forms of bloodletting, enjoyed a revival in the early nineteenth century, particularly in France, where the doctrines of heroic medicine preached by Broussais[176] led to an increase of leech usage from about 3 million in 1824 to 41.5 million in 1833.[177] Leechers, although not as high in status as professional cuppers, practiced in many large cities, and numerous tracts were written on the care and breeding of leeches. "Leech farms" were unable to increase the leech supply to meet the rising demand, and most leechers complained of the scarcity and great expense of the little animals.[178]
Leeching and cupping each had their advocates. The major advantage of the leech over the cup was that the leech could be employed on almost any part of the anatomy, including around the eyes, in the mouth, the a.n.u.s, and the v.a.g.i.n.a. In fact, leeching the internal membranes enjoyed quite a vogue in the early nineteenth century. Leeches were applied to the larynx and the trachea for bronchitis and laryngitis and for relieving the cough of phthisis. For inflammations of the conjunctiva (the membrane lining the eyelids) they were applied to the nasal membrances of the adjacent nostril, and for inflammations of the ear they were applied to the meatus of the ear and behind the ear. The French popularized the practice of leeching the a.n.u.s to treat inflammations of the mucous membranes of the bowel. To prevent leeches from getting lost in the body cavities, Jonathan Osborne, a British physician, recommended in 1833 that a thread should be pa.s.sed through the leech"s tail. In addition, he invented a device, which he called a "polytome," specifically for introducing leeches into the r.e.c.t.u.m.[179] In the mid-nineteenth century, special leech tubes were widely sold for applying leeches to internal membranes.[180]
A second advantage of leeches over cupping was that leeches could extract blood more readily. Not only was dexterity not required in order to apply a leech, but also it was soon noticed that leech bites continued to bleed even after the leech let go, while scarificator incisions often coagulated before any blood was obtained. In 1884 it was shown by John Berry Haycroft, a Birmingham chemist, that this phenomenon was due to an anti-coagulant, now called "hirudin," that the leech injected into the blood.[181]
To apply a leech, the animal was first dried with a bit of linen, and the skin of the patient was prepared by washing with warm water and then shaving. To direct it to the right spot, the leech was often placed in a small wine gla.s.s that was inverted over the area to be bitten. Since leeches were sometimes perversely unwilling to bite, they were enticed by the placement of a bit of milk or blood on the patient"s skin. Small children were given one or two leeches, and adults 20 or more. Broussais employed up to 50 leeches at one time.[182] The leech was usually allowed to drop off of its own accord when it had satiated itself, which took about an hour. Sometimes the tail of the leech was cut off so that it would continue to suck. Once used, leeches could not be reused for several months unless they were made to disgorge their meal by dropping them in salt water or weak vinegar. A healthy leech drew one or two fluid drachms of blood, and as much would flow after the leech had dropped off. Thus a good Swedish leech could remove about an ounce of blood. This quant.i.ty could be increased by employing a cupping gla.s.s over the bite.[183]
Leeches were kept in a gla.s.s container of water covered with gauze or muslin and placed in a cool, dark room. The water had to be changed frequently, as much as every other day in summer. Pebbles or moss were placed in the bottom of the vessel to aid the leech in removing the slimy epidermis that it shed every four or five days. In the nineteenth century leeches were often sold in drug stores from large, elegant containers with perforated caps. Actually, only the day"s supply of the pharmacist"s leeches was kept in the attractive storefront jars; the rest were kept out of sight. While most leech jars were simple white crockery pieces with "leeches" lettered in black on the front, some leech jars were over two feet tall and decorated with elegant floral and scroll work. Among the most ornate leech jars were those made in Staffordshire, England.[184]
(Figure 20.)
_Artificial Leeches_
One of the characteristics of nineteenth-century technology was the attempt to replace natural materials and processes by imitations and mechanisms. Considering the properties of the natural leech, it is no wonder that very early in the nineteenth century inventors began to seek a mechanical subst.i.tute. The disadvantages of the leech were many. Wrote one inventor of an artificial leech:
In the first place the appearance of the animal is repulsive and disgusting, and delicate and sensitive persons find it difficult to overcome their repugnance to contact with the cold and slimy reptile.
This is especially the case when it is a question of their application about or within the mouth. Then again, their disposition to crawl into cavities or pa.s.sages results sometimes in very annoying accidents. Another source of annoyance is that they are often unwilling to bite--the patience of all concerned being exhausted in fruitless efforts to induce them to take hold.
The expense, too, of a considerable number is by no means trifling.[185]